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Who (or what) is Orac?

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Location: The Liberator, somewhere deep in Federation space, United States

Orac is but a humble pseudonymous surgeon/scientist with an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his miscellaneous verbal meanderings, but just barely small enough to admit to himself that few will. That Orac has chosen his pseudonym based on a rather cranky and arrogant computer shaped like a clear box of blinking lights from an old British SF show whose special effects were renowned for their early 1980's BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction for television ever produced, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.) Orac tries to keep his insolence respectful, but admittedly sometimes fails in the cases of obvious quackery and pseudoscience, attacks on him, very poor critical thinking skills, bigotry, and just general plain stupidity.

What is Respectful Insolence?

Respectful Insolence is a repository for the ramblings of the aforementioned pseudonymous surgeon/scientist concerning medicine and quackery, science and pseudoscience, history and pseudohistory, politics, and anything else that interests him (or pushes his buttons). Orac's motto: "A statement of fact cannot be insolent." (OK, maybe it can be just a little bit insolent.)

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Insolent Disclaimer

This is a personal web log, reflecting the sometimes prickly opinions of its author. Statements on this blog do not represent the opinions of anyone other than the author. They most definitely do not represent the opinions or position of the author's hospital, university, surgical practice, or partners. The information on this blog is intended for discussion and entertainment purposes only and not as recommendations on how to diagnose or treat illnesses. Any personal medical issues the reader may have should be referred to the reader's physician. If the reader freely chooses to follow the opinion of a pseudonymous blogger like the author (who has also not done a proper history or physical examination and whose credentials cannot be verified) over that of his or her own personal physician, it is the reader's decision alone, for which the reader must bear full responsibility.

E-mail policy: All e-mail replies to Orac in response to material posted to this blog are subject to being publicly reprinted on Respectful Insolence solely at the discretion of Orac. Requests not to publicly reprint an e-mail will certainly be considered on a case-by-case basis, but Orac offers no guarantee that he will honor them (especially if the e-mail in question is obnoxious, threatening, or insulting).

Friday, October 28, 2005

Prometheus has, after a long delay, finally posted part 2 of his advice for budding quacks everywhere. In this case, he explains how to exploit your niche. For me as a physician, perhaps the most relevant piece of advice is here, given how HMOs have taken financial control of most medical practices:

Whatever you do, do not make the mistake that many chiropractors are making - do not try to get your services covered by insurance plans. This is the kiss of death for "alternative" practitioners. Although getting covered by health insurance plans may yield a better cash flow for the marginal "alternative" practitioner, it is a disaster in the long run.

Just look what insurance coverage did to the "real" doctors . The ones who were getting paid in chickens (when they got paid at all) did better, but the profession as a whole ended up saddled with endless paperwork and red tape. Eventually, the insurance companies ended up telling the doctors how much they would get paid for everything they did. Makes getting paid in chickens and corn look good by comparison.

Bottom line: even if you could do it - stay away from insurance companies (this includes the biggest insurer of them all - the Government). You don't need that kind of scrutiny and you surely can do without the paperwork. After all, if you wanted to fill out forms, you would have become an accountant.

If any of your "clients" ask why you don't accept insurance, there are a number of good answers you can give:

[1] "The insurance companies are a part of the conspiracy to keep people sick - I'm trying to keep people well."

[2] "My therapies are too much on the cutting edge - insurance companies still call them 'experimental'"

Or you can think up something that fits your particular style of business.

Indeed. Insurance companies, whether you agree with them on the specific criteria they choose to evaluate what they will pay for or not, do tend to have this nasty (for quacks, anyway) tendency to require some evidence of efficacy before they will pay for a treatment, all from a desire to minimize cost and maximize profits. On the other hand, the chiropracters' desire may not be that misguided for two reasons. First, if enough patients want it, insurance companies will often pay for a treatment, even if evidence from well-designed clinical trials for its efficacy is lacking, such as vertebroplasty or, back in the 1990's, bone marrow transplantation for more advanced breast cancer. Insurance companies will sometimes do this to prevent the loss of subscribers unhappy that they won't pay for such treatments. Second, having insurance companies reimburse you for services cloaks you with the mantle of "respectability," of being part of mainstream medicine. This is invaluable, even if it does bring with it the headaches of paperwork, the insurance company dictating how much it will pay for what procedure, etc.

Finally, of course, Prometheus insists that you emphasize these three points:

[1] All the doctors they have seen in the past were incompetent (they may have already told you this) [Orac's note: I'm not sure I like this one...]

[2] You know exactly what is wrong with them - and it's not due to anything they did, like smoking or overeating. Blaming the government or large multinational corporations can be useful at this juncture. [Orac's note: This one is absolutely key. Quacks have to convince their marks that they are somehow "poisoned" and that it is not their fault. Blaming mercury in vaccines or from amalgams is a good example of this ploy. Using various "liver flushes" and enemas are other examples of treatments based on ridding the body of undefined "toxins."]

[3] You are the only person (or one of a select few) who can cure them (or at least return them to health and the need for a life-long maintenance program).

4 example(s) of insolence returned:

Talking with a friend in medical research, she pointed out that one of the biggest benefits from a single payer health system would be the ability to collect large amounts of data on the efficacy of various treatment methods (or at least get good ideas of where to do more substantial studies). A government health service, as the only payer/provider, would also be able to enroll far more patients in studies than is now the case.

One reason why insurance companies might be willing to cover some sCAM "treatments" would be to placate the "worried well" who might otherwise overutilize actual medical resources. It's probably cheaper to send the "I *know* there's something wrong with me, but none of the doctors can find it" person to a chiroquactor or naturopathetic for a one-time visit than to let him keep seeing specialists (of course, the carrier should pay *only* for a one-time visit, not "maintenance therapy").

I am sorry if you took offense or exception to my suggestion that the quack tell the mark that "all the other doctors you have seen are incompetent". This is, however, the story I have heard from way too many people who are patrons of the "alternative" fringe.

And since the patients are already telling their quacks (and their real doctors, too, I imagine) that everyone who has treated them before has been incompetent, it would seem only natural to agree.

I can only imagine what it must be like - to a real doctor like yourself - to have someone come into your office and lay out a tale of woe and calamity about how none of the three hundred and twenty-seven doctors they have seen before were any good. The temptation must be to say, "Well, I probably won't be able to help you either. Why don't you just get on out of here right now?"

To the quack (or novice doctor), the impulse to agree with the patient and to be that "one in a million" (possibly literally) who can help them must be overwhelming.